To make health insurance policy (Mediclaim) logical, practic
Dr. Hemant Patel
To make health insurance policy (Mediclaim) logical, practical and efficient to achieve the goal of ‘HEALTH FOR ALL’
Sub: To make health insurance policy (Mediclaim) logical, practical and efficient to achieve the goal of ‘HEALTH FOR ALL’

At present less than 15% of Indian population having health insurance, means more than 85% people have not health insurance cover. They pay for health from their pockets.
In insurance sector, health insurance (mediclaim) also plays an important role.
However, for all general insurance companies health insurance (mediclaim) is loss-making segment.
In spite of increasing premium, every year insurance company’s loss of that particular (health) segment is also increasing.
Disputes between insurer and company are increasing day by day.
Private and corporate hospitals are charging tremendously for ordinary illnesses, which can be treated in clinic on OPD basis at nominal cost.
As medical personals, I observed the pattern of mediclaim functioning & claim settlement.
(1) Only indoor cases considered for claim.
(2) More than 50% of claims are from patients suffering from infectious diseases like malaria, typhoid, pneumonia, diarrhea, fever etc.
(3) All these type of cases are treated by family physician (called family doctor) routinely at an average cost of Rs.300 to Rs.3000 per case including investigations, medicines, and injections with intravenous therapy.
(4) But as per terms and conditions of mediclaim policy patient has to admit as indoor patient for at least 24 hour for reimbursement from mediclaim. So, patient who suffers from simple illness (like malaria, diarrhea, uti etc.), which can be treated as OPD basis at maximum 3000 Rs(inclusive of all) will be admitted in hospital for the same and insurance company are paying minimum Rs.15, 000 to maximum up to Rs.40, 000.
Due to existing terms and conditions of mediclaim policy, all hospitals are charging excessively.
Ultimately, insurers have to bear all financial burdens.
Irony is that an insurer, who never claim for single rupee from company and pays his premium regularly, suffered in the form of more premium payment without any fault.
Now, questions come that how insurance company and insurer both will be benefited and make health insurance sector profitable?
How leakages of mediclaim policy will be minimized at the same time insurer will get various options at an affordable price?
How dispute between company and insurer can be minimized?
Today only one or two plans of mediclaim policies are available.
(A) Keeping existing policy plans continue, few measures will help both company and insurer.
(1) Some percentage (say 10%) of claim amount must be paid by insurer (It already exists in USA).
(2) Excluding accidental cases prior to indoor admission insurer must be examined by family physician and reference (recommendation) letter for indoor treatment should be mandatory. It can be tie up with above (1) condition.(i.e. if person admit directly without family physician’s reference note he/she has to bear 10 % of total bill.
(3) Reimbursement for OPD treatment for infectious disease by registered medical practitioner should be considered in mediclaim policy.
(4) New policy, which covers hospitalization excluding infectious diseases (that treated medically), should be introduced. I.e. mediclaim covers cardiac, renal, neurological, cancers, liver diseases etc, infectious disease treated surgically and accident cases. These are the diseases, which should be really taken care of as indoor patient. (Gujarat branch of Indian medical Association is running such type of scheme in which two members are getting cover of 3.5 lacs at an annual premium of only 1050 Rs. per person.) Company can offer this type of mediclaim at very cheaper rate.
(5)Policy that covers only accident case should introduce.
(B) Premium calculation should make logical and scientific by following measures.
(1) Instead of considering mediclaim as a whole throughout the country, mediclaim policy should be categorize according to plan wise and city wise .i.e. city under category A (Delhi, Mumbai, Kolkata, Chennai i.e. more than 1crore of population), category B(Ahmedabad, Bengaluru, Kanpur, Bhopal, Jaipur etc.i.e. 50 lacs to 1 crore of population) category C( Noida, Nagpur, Baroda, Surat, Rajkot, Kochi, Lacknow etc.( i.e. between 10 to 50 lacs of population) and category D (less than 10 lacs of population) like that. During Profit/ Loss and Claim ratio and premium calculation, plan & city category should be considered.
(2) Instead of hiking premium of all mediclaim policy equally throughout country and all policyholder to cover high claim ratio, premium to claim ratio of each compartment should considered separately at the time of premium calculation. It will prevent leakages and only those policy holders will be affected who are in that particular compartment.
(3) During deciding the premium amount, total claim amount of company for that particular plan and city category should be considered and loss due to higher claim ratio, amount should be passed on (in a form of premium hike) to only that particular compartment of policy.
By editing in existing online software, company will get all above types of data and reports at fingertip. This will help company to make whole mediclaim policy very logical, effective, transparent, efficient and leakage proof.
(C) Instead of TPA, insurance company appoints qualified medical professionals in their
office to verify claims.
After TPA era, disputes in consumer court have increased.
Advantages of mediclaim excluding infectious diseases are
(1) People can have various options to choose.
(2) It will reduce the claim ratio drastically and workload of company too.
(3) It will prevent unnecessary hospital admissions (for malaria, diarrhea etc) when our country has too high patient to hospital bed ratio.
(4) Company can provide policy at cheaper premium. Therefore, large section of society who still not covered under mediclaim can be covered.
(5) Problem of fake (bogus) claims will reduced.
(6) By mediclaim policy, which covers only accident, lives of truck drivers can saved who haven’t have any medical policy now.
With warm regards,
Thanking You,Sincerely Yours,
Dr. S●●●r P●●●●●●●i and 1 others like this